ML19322C512

Mgt Approach in Accident Prevention

ML19322C512
Person / Time
Site:	Crane
Issue date:	06/17/1976
From:	Fine W NAVY, DEPT. OF
To:
References
TASK-TF, TASK-TMR NUDOCS 8001170841
Download: ML19322C512 (22)

Text

17,197p a u. m Return to C. O. Miller U. S. DEPARTMENT OF LABOR Occupational Safety and Health Administration Washington, D. C. 20210 l

1976 9

REGIONAL FEDERAL SAFETY AND HEALTH CONFERENCES BOSTON MARCH 910 DALLAS MARCH 24 25 LOS ANGELES MAY 25 26 ATLANTA JUNE 1617 A MANAGEMENT APPROACH IN ACCIDENT PREVENTION BY WILLIAM T. FINE, P.E., CSP NAVAL SURFACE WEAPONS CENTER WHITE OAK LABORATORY SILVER SPRING, MARYLAND 20910 V

0[

lW. a j!

. :p$

.v ;

S f f / [+

800117

Retum to C. O. kaller WHITE OAK LA8oR AToRY SILVER SPRING. Mo. 20910 e

oA NAVAL SURFACE WEAPONS CENTER 82'2" " -1345 "3

HEADQUARTERS DAHLOREN LAsoRAtoRY

/

OAHLGREN. VA. 22444 WHITE O AK, SILVER SPRING. M ARYLAND 20910

.g n

PREFACE A 5fANAGDfENT APPROACH IN ACCIDENT PREVENTION This report gives a description of a unique loss-control s: stem that greatly improves the overall effect and efficiency of accident prevention activities. The report is presented in a format to facilitate its adoption by any organization.

The technique was created and developed by the author in recognition of accelerated emphasis on economy of operations.

It reduces waste and losses by using accidents, unsafe practices, and the exiatence of hazards as indicators of management failures that are causing unnecessary productive losses.

The benefits of impi smentailan of this system at this Laboratory during the past several years have been twofold: it has been instrumental in further improving a safety program that was already outstanding; and it has helped supervisors and managers recognize and control many costly inefficiencies, errors and oversights.

I believe it is a mzjor improvement in the technique of accident prevention, with pot ential for universal application by safety professionals thr)ughout government and industry.

9

%JP

W. T.

PO Captain.

'S4 Officer-in-Charge White Oak Laboratory f

1

A MANAGEMENT APPROACH IN ACCIDENT PREVENTION INTRODUCTION GENERAL. During times when economy of operations is in vogue, managements of organizations often endeavor to reduce costs by streamlining productive operations, reducing purchases of new equipment, decreasing numbers of maintenance and overhead employees, and by other such measures that may be objectionable although considered necessary. But now, a unique system in safety programming provides the potential for easily accomplishing considerable monetary savings and productive improvement, as well as eliminating accident causes, without costly expenditures and without cutting down on operations, personnel, or services. Only waste is reduced.

This system is not simply the common approach of safety people who endeavor to justify safety programs by computing and dwelling on the costs of accidents such as medical expenses, compensation paid, property damage, administrative lost time, and various indirect costs. This system is a way to achieve savings.

The technique stems from the simple action of recognizing that all accidents and hazards are indicators of management failures; and that these management failures are causing many productive losses as well as accidents.

Investigations quickly show that these failures, which may be simple inefficiencies, errors, or oversights, often exist for years and continually cause huge losses, without anyone knowing about them. But accidents and hazards can be routinely analyzed so as to be a means of detecting them. Once identified, most management failures are easily corrected.

HYPOTHES IS.

In the investigation of any accident, there can always be found some degree of management involvement or activity that might in some way have prevented tha accident. Therefore, it is arbitrarily assumed that Management will be responsible for the causes of every accident, at well as for the existence of every hazard.

With this hypothesis, the investigation of each accident, and of each hazardous situation noted, will be directed to seek to identify that underlying management involvement.

i

DEFINITIONS. To assure proper understanding of this process, it is necessary to clarify the meaning and intent of two key words in this system,

" Management" and " Failure".

Definitions are as follows:

" MANAGEMENT" is defined as including all levels of supervision higher than the immediate supervisor. Also included in Management are all administrative and support agencies such as the Personnel Office, Engineering or Planning Groups, plant maintenance shops, supply agencies, the safety organization, Security, etc.

It is emphasized that the immediate supervisor is not included as a part of Management for the purpose of employing this approach. Contrary to common safety philosophy, the " key to accident prevention will be considered the higher levels of management, not the immediate supervisors.

" FAILURE" is defined an any action or omission which can cause or contribute to an accident, to the existence of a hazard, or to the commission of an unsafe act.

It can be called a failure, an error, an oversight, or an inefficiency.

APPLICATION OF SYSTEM The system is applied by investigating each accident or incident and each hazardous situation that is noted, with general management introspect.

In each case, we must endeavor to get an answer to the question: "WHERE DID MANAGEMENT FAIL 7" Determination is made as to whether any element of management took some action which precipitated the unsafe situation, or failed to take some action which could have forestalled it.

The management failure may be obvious in one case, or a remote contributing factor in another.

The functioning of the system will be explained and demonstrated by its application to actual cases of hazardous situations that have been noted on safety inspections, or have come to attention due to minor first aid injuries being reported.

While examples are based on factual occurrences, places and events have been altered to avoid identification and possible embarrassment of individuals or organizationa.

9 9

3

~ _ _ _ _ _. _. _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ - _ _ _ _ _ _ _. _ _ _ _

1

~

l i

l The system is used continuously by safety personnel during their inspectional j

or investigative procedures. Examples follow.

,1 W7"

,W;a.

[-

I t

f 4

{

x

,'r t

4

'l l

1 l

I

?

l y

t

}

Jllt-N m

L N',.

i Illustratior. No. 1 i

First Situation. Referring to Illustration No. 1, inspectors have noted a machine in use without a belt guard.

This hazard could simply be written up or noted as a violation with advice to have a guard fabricated for the machine, the normal approach 2n most such I

cases.

But upon inquiry into possible management involvement, the supervisor pointed out that this was a new machine that had been delivered in this condition and he felt that it couldn't be a serious hazard or the manufacturer would have remedied it.

Upon further investigation, it was found that safety requirements had not been specified in the purchasing order for the machine. To tie this oversight to some element of management, it was found that the Safety Department had a degree of responsibility for this hazard since it was a policy that Safety would review purchase orders to insure that necessary safety features were always specified.

Here, a safety inspection revealed a case of lack of coordination between Safety and Procurement, a management failure.

4

% ;fb @ f'N D

Dr k al+

l

?

I i

I l

a l

'Ibe next step was to look for possible monetary or productive losses, as well l

l as hazards, due to the effect of this management oversight throughout the plant.

A substantial loss was quite obvious. This oversight, the Procurement and Safety Departments not properly coordinating, was putting an unnecessary burden on a number of supervisors, endangering their personnel and adding to their work.

For example, it was found that a number of hazardous machines or unsafe equipment had been purchased, such as portable power tools without ground wire systems, because of this error.

i Correction of the error was speedily and easily accomplished.

Improved coordination between Safety and procurement forestalled a number of hazards, I

provided supervisors with safer equipment, tools and materials; and thereby gave supervisors more time for and less diversion from their productive work.

It is significant to note that such plant-wide benefits would not have l

developed if the violation of the unguarded belt had simply been corrected.

l ' ',

w.

.- w as-..a

~

,v.

2 g

~

4 M,

A e

J

/%

a %e Ah' Illustration No. 2 1

Second situation. Referring to Illustration No. 2, an inspector has.noted a hammer which has a cracked handle that has been taped on.

Ordinarily, a carpenter or mechanic would be mildly admonished for using or having in his possession a hammer with a cracked handle. This would be considered a minor hazard, perhaps so insignificant that some inspectors would ignore it.

aL%

5 I

,~.-.-,.----_,--..n-

However, this minor hazard is a clue to other hazards, and also to a very costly management failure.

With an investigation into possible management involvement, it was found that the Supply Department stock limits on hammers and on replacement handles had been set too low.

This investigation brought to light the fact that the stock was depleted most of the time.

Therefore, the users had to make repairs, or improvisa At this point it still may seem like a very minor oversight, until we look at the probable loss.

It was found that the stock of hammers and handles had been depleted most of the time, over a period of several years.

Each day an average of four shop employees have had a need for rep?.acement handles, they have taken the time to go to the Supply Store to get them, and have found there were none in stock. They would return to their shops, " gripe and groan" and discuss the inefficient system with others, and eventually decide to do the best they could with what they had.

Some would continue to use their defective hammers, some would tape them up, and others would improvise or substitute for a hammer by using a heavy wrench or some other tool, and thereby damaging the other tool and the work.

In every case, they undoubtedly did a less efficient job than they would have done with proper tools.

A conservative estimate of the amount of time lost each time an employee sought a new hammer or hammer handle, is one half hour.

If this situation occurred four times every day for years, and that is a good presumption, we must certainly have incurred many thousands of dollars in costs due to the management oversight that caused this small hazard.

Investigation of the inadequate stock limits on hammer handles brought to attention inadequate limits on a number of other items also, all causing similar losses, and all due to a little unnoticed inefficiency by one stock clerk.

Improved supervision in the stockroom eliminated the inefficiency and there-fore a number of continually recurring hazards, as well as many losses.

It is emphasized that these benefits were obtained because the minor violation of the taped up hammer handle was not simply noted and corrected, but the case was investigated to determine higher level management involvement.

e e

6

A M

s\\

s n t,-t.

s

'v gy - ~ ?,

^ '

i s

~

4 l

)).,%

Illustration No. 3 For the third situation, see Illustration No. 3, we have an improvised scaffold constructed of stepladders, planks and beams, and fastened with ropes.

There is no question that it is unsafe, with potential for a serious injury or fatality. Rather than simply correcting this situation, it was investigated to determine if there were some underlying management errors. Results of the investigation were quite surprising.

It was found that - a properly manufactured scaffold was not available for the crew using this scaffold because someone in a higher management position was endeavoring to operate at the lowest possible costs, avoiding purchases of new equipment.

It was also found that this scaffold had been assembled and disassembled, in order to be relocated or when a job was finished or started, at least once per week throughout the previous year, and probably for a longer time.

D"~D

• W'p f ITIl @i

~

.}\\

j'f [

7

j I

Each time the scaffold was removed or erected it required three to four men working about three hours. While it was in use, it required frequent inspection and tightening up; and the men working on it were never at ease.

These factors are to be compared to the situation if a new scaffold were obtained: two men could erect a proper scaffold this size, in one half hour. By some simple arithmetic it was shown that an investment of $1,000 for a new i

scaffold could save $10,000 to $15,000 annually, and incidentally greatly improve the safety status and efficiency of several men.

J This amount of saving would result from improving this one case of scaffolding.

But this case brought to the notice of the Department's Top Management the policy in effect of a number of its middle managers being " penny wise and pound foolish" - saving a few cents but incurring tremendous hidden costs. Changing this policy throughout the department brought about a l

tremendous saving, and incidentally, eliminated many hazards, i

Again, it must be noted that the benefits occurred because the situation l

was investigated specifically for management involvement rather than with the objective of simply eliminating the obvious hazards.

For the next situation, three men are shown in Illustration No. 4 lifting an

(

overloaded cart up a curb.

l i

l IQ

)-

M

.%.;)ci{M su ma+

,V

.e

.t i

%sq 3

i Illustration No. 4 m :1 Qr;r ww l 8

c, m---.

-.n..---

,.,.w

The employee delivering' material with the cart had asked two other men to aid him at this point.

This case came to the attention of the Safety Department when the employee who normally uses the cart reported to the Dispensary for first aid trea. ent because he had incurred a slight back strain.

The routine safety solution to this unsafe situation would be to advise the supervisor to give instructions to reduce the load, or not to try to go up the curb - stay in the road.

The caso could have easily been disposed of as one of those " unpredictable or unavoidable minor injuries".

But the in-depth investigation revealed almost a constant use of this hand cart over rouga terrain. There was no doubt that the cart was unsuitable for its type of use; the wheels were too small for rough terrain.

However, the department managers did not desire to invest in a more suitable vehicle - one with larger wheels and removable side racks, the cost of which would have been about $200.00 "Too much money", said someone up the line.

"You've got a cart.

Use it."

This operation was evidently considered minor and not important enough to rate new equipment.

However, a survey showed that the one man assigned to the use of this cart had to find someone to help him as shown in the illustration, an average of three times per day.

Figuring the time lost by the cart man plus one or two helpers three times per day, the cost or loss is easily computed to 2 to 3 thousands of dollars annually - to avoid spending $200.00, another clear example of misdirected effort at economizing.

The result of this investigation ius that the very small investment for a new cart greatly reduced the possibil' x of further back strains, greatly improved an employee's morale, undoubt J1y expedited deliveries of material, and created considerable monetary savings.

By publicizing this case, other supervisors and managers were persuaded to observe their operations and facilities more closely with a view to making similar improvements.

There are many improved labor saving devices and equipment on the market that will reduce hazards and at the same time greatly increase production.

But, sometimes we shy away from such investments.

This case is not remote or uncommon. Similar situations can be found in practically all organizations.

For the next example we will consider the ramifications of an in-depth intestigation of a poor housekeeping situation.

9 1

1 i

This condition was noticed during a routine safety inspection.

See illustration No. 5 l

[

f'

=7 A

'l e

a

,m j

'S k4

._ i 1

f j

.t

~

i

)

~

i

4

']

a j

(

M Illustration No. 5 Any safety inspector would get this fire hazard eliminated imme'diately.

'Iha t would be quite easy to accomplish, because the hazard is indisputable. However, since it occurred this time, it is possible and quite likely that a similar situation would reoccur perhaps in the same place, or elsewhere, unless the underlying cause, or the management failure that allowed it to develop were identified and eliminated.

An in-depth investigation to seek management involvement revealed that the old rugs were being carried on stock records for no good reason that anyone could state, except that it was the policy of the accountable office to hold such used material for a number of months, even years, before disposing of it.

l This case of the rugs turned out to be something like the "tip of an iceberg" which forecasted vast waste of valuable productive space due to unnecessary l

storage of replaced equipment, machines and material which had no real expectation of use.

Such storage created hazards as well as handicaps and delays to productive operations.

10

, l

Changing the policy and disposing of surplus material with less delay brought about many benefits such as :

imp"ovements in safety conditions by eliminating fire hazards, congestions and poor housekeeping; and making more space available to properly plan and layout productive operations.

The key point for emphasis is that an obvious hazard as illustrated here should not simply be removed.

That, as a medical doctor would say, would be

" treating the symptom, not the cause."

We must determine the management oversight that allowed the hazard to develop, and endeavor to establish management policy that will prevent such hazards and productive losses and waste from forming.

The next example pertains to repair work on a large generator in a machine shop. Due to limited working space, the mechanic doing the repair work had to work in an awkward position. As he exerted pressure on a wrench, he bumped his head on a projection on the side of the generator and received a laceration.

The routine approach and corrective action kould be cautioning of the employee, with advice to move materials to give himself more working area.

i But the " Management involvement investigation" revealed that the generator I

was old and decrepit, and should have been overhauled or replaced some years ago.

Such action had been avoided or postponed by department management for reasons unknown.

It was found that the generator had been repaired at least once per week for at least the past year, with : apair time averaging three hours each time.

The generator was used to supply power for the operation of 5 other machines.

When the generator was down, two or three machinists or operators had to wait, or find other odd jobs while the generator was being repaired.

Thus there was a cost or loss of at least three employees, the repairman and two or three others, for three hours, once per week.

Arithmetically, the loss is computed to be 450 man hours or $9,000.00 per year due to management's failure to replace the machine when it became uneconomical to continue in use.

In addition, a further investigation revealed that the generator could be eliminated by providing an alternate source of power from two other nearby generators, at a cost of approximately $200.00 for electrical wiring and materials.

Let us summarize the benefits that resulted from the investigation of management involvement of this first aid injury. Most important, a source of i

potential injuries was eliminated, the repetitive repair work in a congested area.

Secondly, this accident preventive action brought about a monetary saving of approximately $9,000 per year, for a cost of $200.00.

i It is again emphasized that these benefits would not have resulted from a cursory investigation or a " brush-off" as is of ten given to first aid injuries.

11 l

l

l l

l Materials handling operations are prevalent sources of accidents, injuries, and inefficiencies.

l e

h'l

.-k l

r -

w~.

i; IEni i

s.

Illustration No. 6

^ k

)[\\ \\

..~4 g,

N

.a

_

4

. L Ni i

w I

f l

l l

Illustration No. 7 12 Ti 3 J

i In the next example, (see Illustrations No. 6 and No. 7), two men are transporting a barrel of material from a mechanical material lif t which brought it up to this level from the floor below.

The barrel weighs 80 pounds.

The two employees now have to carry the barrel by hand up the stairs to the next floor where it will be used.

This materials handling operation is performed an average of five times per day.

This operation was noticed when one of the employees reported a slightly strained back. A few inquiries turned up the information that a mechanical lift to take the material up to the next floor had been suggested and considered in the past.

It had not been installed because the estimated cost of $2000.00 was considered excessive.

Considering the situation from the safety viewpoint, it is a very hazardous operation. A slip could cause a man to fall down the stairs with material falling on top of him.

A mechanical lift would be an excellent safety improve-ment.

The question is asked:

Did Management Fail? If so, where?

It was found that each trip carrying the material by hand as illustrated required ten minutes, while a direct mechanical lif t would do it in two minutes.

Thus, the mechanical lift would save 8 mi".utes per trip.

Eliminating five such trips a day for two men would save 80 minutes per day, or 400 man hours per year or $8,000.00 per year.

At this rate, the mechanical lif t would be paid for in two months, and from then on - there would be a good profit on the investment.

It must be emphasized at this point that safety investigations should not be motivated principally for profit and efficiency, except when such factors can be tied into elimination of hazardous situations in order to get management support.

The above case illustrates how a management type investigation of a first aid injury provided ample justification for valuable safety engineering action that eliminated a very hazardous operation, action that would not have otherwise been taken.

We could go on with many more examples. Similar management failures can be noticed every day in every organization, if we seek management involvement in the causes of accidents and hazards. Management errors, or oversights, will be revealed in just about every first aid injury and every hazardous situation noted during an inspection.

1 Each individual case must be brought to the attention of the Management level

{

or the agency concerned or involved in the situation as soon as possible. The case should be taken directly to the person who is in the position to take the

{

necessary corrective action.

Taking a case to higher levels than necessary should usually or normally be avoided to avoid embarassment of the managers who were involved in failures. This procedure of individual action is the first half of the system.

13

GENERAL PREVENTIVE ACTION Can general preventive action be instituted collectively, to eliminate the repetitions of management failures that are noted? This can be accomplished very effectively.

We are enabled to see the BIG PICTURE, that is, where various types of errors are occurring repeatedly, by placing all the possible errors, oversights, or inefficiencies into general categories and " charting" them as they occur.

SlN ARY CHART OF MANAGEE NT FAILURES THAT CAUSE ACCIDENTS 1974 INADEQUATE l JULY AUG SEP OCT NOV lit il i

II 1.

PLANNING, LAYOUT, DESIGN 2.

SAFETY RULES, MEASURES, EQUIPMENT I"

3.

ENFORCEMENT OF SAFETY RULES, MEASURES l'

4.

OPERATIONAL PROCEDURES

$* M

$7 $ "" ",,*

5.

ENFORCEMENT OF PROPER PROCEDURES M"

6.

SUPERVISORY PROFICIENCY 7.

SUPERVISORY SAFETY INDOCTRINATION

/

8.

EMPLOYEE TRAINING "I

9.

EMPLOYEE SAFETY CONSCIOUSNESS 10.

EMPLOYEE SELECTION, PLACEMENT I

'I

/

11.

EQUIPMENT, MATERIALS, TOOLS

/

12.

MAINTENANCE, REPAIR OF EQUIPMENT 7/,* 7***

Illustration No. 8 The Management Failures Summary Chart is shown in Illustration No. 8 The lef t column is made up of a list of general management failures, one or more of which can in some way be r ssponsible for practically every accident, as well as for the existence of every hazard. Each "tickmark" indicates an inadequacy or failure at or by some level of management above the immediate supervisor.

14

Any concentration of minor management errors obviously means that there is a major problem.

In the case illustrated, we see two major problem areas: item 4 Inadequate Operational Procedures: and item 12, Inadequate Maintenance of Equipmen t.

The tickmarks represent those errors that have been found and probably corrected. But where similar errors continue to occur, as shown by concentrations, it can be assumed that many more errors or inefficiencies remain to continue to cause accidents and other losses.

Thus this chart can be used as an excellent guide as to what areas of preventive action require intensification of effort.

This summary chart can also be compiled for individual departments or subdivisions of a plant, so that the predominant problems of each department can be determined.

Unfortunately, some members of Managements may be primarily interested in productive efficiency, but only mildly interested in safety. With this approach, such managers can still be motivated to eliminate hazards by showing the losses caused by the deficiencies.

If they agree to undertake to improve the unsatisfactory situations in order to prevent productive losses, rather than to prevent accidents, safety will still profit even if as a by-product or fringe benefit.

METHOD 'ID DERIVE OR DETERMINE MANAGEMENT FAILURES This system differs from conventional accident prevention procedures in that each case of an accident or a hazardous situation noted is " tracked back" to management errors or oversights, starting with the primary unsafe acts or conditions. A logical procedure to do this can be easily followed.

The immediate reasons for the commission of unsafe acts and the existence of unsafe conditions are usually quickly apparent or easily discovered. However, a fair degree of expertise and judgement are required to track these causes back to the management failures that created or contributed to their existence.

Below is given a list of 15 basic accident causes, one or more of which will be responsible, contributory to,or involved in practically all hazardous situations.

1.

Poor housekeeping 9.

Lack of proper tools, equipment, 2.

Improper use of tools, facilities eq uipment, facilities 10 Lack of guards, safety devices 3.

Unsafe or defective equipment, 11 Lack of protective equipment, facilities clothing 4

Lack of proper procedures 12.

Ev 'eding prescribed limits, load, 5

Improvising unsafe procedures speed, strength, etc.

)

6.

Failure to follow prescribed 13 Inattention; neglect of obvious procedures safe practice 7.

Job not understood 14.

Fatigue, reduced alertness, 8

Lack of awareness of hazards hypnosis involved 15 Misconduct; poor attitude I

15 l

l l

Consider the first cause listed: poor housekeeping. The objective is to accurately derive general management failures that led to poor housekeeping situations. Examples of poor housekeeping accidents are:

a.

An employee trips and falls over equipment lef t in an aisle.

b.

Material poorly piled on a high shelf falls off.

The most probable reasons or underlying causes for these accidents are:

a.

The hazards were not recognized.

Employees and/or the supervisor did not consider that the equipment in the aisle or piled on the shelf constituted a hazard, and so did not remove it.

Or, b.

Facilities were inadequate. Sufficient space for proper storage was simply not available.

For these reasons or underlying causes, we now seek to determine the most probable management failures, If the cause was the hazard not being recognized, obviously the management n.

failure was inadequate supervisory and employee training, and inadequate safety indoctrination.

b.

If the cause was inadequate facilities, the management failure would most likely be inadequate planning at some higher level of the management.

Thus we have translated the causes into general categories of management failures.

In the same manner as above, any and all basic causes can be tracked back to one or more of the general management failures listed on the Summary Chart (Illustration No. 8

).

For general guidance in developing management failures for all the listed basic causes, the following tables give a system.for derivation of the underlying management failures.

16

ACCIDENT CAUSES TRACED BACK 'ID MANAGDfENT RESPONSIBILITIES POSSIBLE POSSIBLE IMMEDIATE CAUSE UNDERLYING CAUSES MANAGDIENT FAILURES INADBQUATE:

1.

Poor housekeeping Ilazards not recognized Supervisory training Examples:

Supervisory safety

• An employee trips and indoctrination falls over equipment left in an aisle.

Facilities inadequate Planning, layout

• Material poorly piled on a high shelf-fells off.

2 Improper use of tools, Lack of skill, Employee training eq uipment, facilities knowledge Examples:

Lack of proper Established operational

• Using the side of a procedures procedures grinding wheel instead Lack of motivation Enforcement of proper of the face, and the procedures wheel breaks.

Supervisory safety

• Someone using forklift indoctrination truck to elevate people-Employee training man falls off.

Employee safety

• Someone using compressed air to clean dust off his clothes - eye injury, 3.

Unsafe or defective Not recognized as unsafe Supervisory safety equipment, facilities indoctrination Examples:

Employee training

• Portable electric drill Employee safety without ground wire.

consciousness

• Axe or hammer with loose head.

Poor design or selection Planning, layout, design

• Car with defective Supervisory safety brakes, steering, indoctrination Equipment, material, tools Poor maintenance Maintenance, repair system 17

p0SSIBLE p0SSIBLE IMMEDIATE CAUSE UNDDtLYING CAUSES MANAGEMEh"T FAILURES INADBQUATE:

4 Lack of proper procedures Omissions Operational procedures Examples:

• No requirement to chec c Errors by designer Planning, layout, design for gas fumes before starting engine-explosion Errors by supervisor Supervisory proficiency

• No definite instructions requiring power to be locked out before maintenance is done.

5 Improvisi.sg unsafe Inadequate training Established operational procedures procedures Enforcement of proper Example:

procedures

• " Rube Goldberg" Supervisory safety haphazard temporary indoctrination expedients, without Employee training proper planning.

Employee safety consciousness inadequate Supervisory safety supervision indoctrination Employee selection, placement 6

Failure to follow Need not emphasized Enforcement,of proper

_ prescribed procedures procedures Examples:

Supervisory safety indoctrination

• Shortcuts bypassing safety precautions.

Procedures unclear Operational procedures

• 0peration will only be done once; take a chance.

7.

Job not understood Instructions complex Operational procedures Planning, layout, design Examplo:

Inadequate comprehension

• Employee ases wrong Employee selection, method, dcesn't follow placement instructionr.

r 18 l

POSSIBLE POSSIBLE IMMEDIATE CAUSE UNDERLYING CAUSES MANAGEMENT FAILURES INADBQUATE:

8.

Lack of awareness of Inadequate instructions Supervisory safety hazards involved indoctrination Employee training Examples:

Employee salaty

• Not realizing rotating consciousness shaft was dangerous.

• Not realizing fumes Inadequate warnings Planning, layout, design were hazardous.

Safety rules, measures.

• Not realizing that equipment hydrogen from battery Operational procedures charging operation could explode 9.

Lack of proper tools, Need not recognized Planning, layout, design equipmen t, facilities Supervisory safety indoctrination Examples:

• Cart too small for Inadequate supply Equipmen t, materials, hauling large items.

tools

• Auto-maintenance done without proper wrenches-Deliberate Morale, discipline cut knuckles 10.

Lack of guards, safety Need not recognized Planning, layout, design devices Safety rules, measures, equipment Examples:

Supervisory safety l

• Machine has exposed belt and indoctrination gear-severe cut l

Employee safety

• No warning horn on vehicle -

consciousness pedestrian hit

• No guard rail on a Inadequate availability Equipment, materials, scaffold 10 ft. high tools Operational procedures Deliberate Morale, discipline, laziness 9

19

P POSSIBLE POSSIBLE IMMEDIATE CAUSE UNDERLYING CAUSES MANAGE'.!ENT FAILURES INADBQUATE 11.

Lack of protective Needs not recognized Planning, layout, design equipment, clothing Safety rules, measures, equipment Examples:

• Eye protection not used Supervisory safety indoctrination in shop.

Employee safety

• Dermatitis because consciousness employee didn't use protective lotion or Inadequate availability Equipment, materials,

gloves.

tools

• Not using respirator Operational procedures when spraying paint.

• Long haired man not Discipline Morale, discipline using hairnet

• Materials handler not wearing safety shoes.

12.

Exceeding prescribed Warnings inadequate Safety rules limits, load, speed, Proper procedures strength, etc.

Examples:

Instructions Employee training

• Driving vehicle too inadequate fast - accident

• 0vertaxing a crane or Lack of Employee training hoist or elevator-comprehension Employee selection, lifting beyond rated placement capacity load drops Deliberate Enforcement of safety rules Employee safety consciousness 13.

Inattention; neglect Lack.of motivation Enforcement of safety rules, of obvious safe measures practico Enforcement of proper procedures Examples:

Employee training

• Welder picking up hot Employee safety metal in bare hands, consciousness

• Driving much too fast.

• Walking under a Inadequate Employee selection, suspended load, comprehension placement

• Not cleaning up broken glass on floor.

i 20

~

POSSIBLE POSSIBLE MANAGEMENT FAILURES IMMEDIATE CAUSE UNDERLYING CAUSES INADBQUATE:

14.

Fatigue, reduced alertness, Excessive physical Planning, layout, design hypnosis or mental Employee selection, requirements placement Examples:

Operational procedures

• Putting excessive hours i

on hazardous machine operations.

• Repetitive inspection of small parts 15.

Misconduct; deliberate Low morale Supervisory training failure to use protective Poor attitude Employee selection, clothing.

placement

• Failure to install safety guards.

Malassignment Planning, layout, design

• Desire to speed (for thrills)

Employee selection, placement Employee training e

e r

21

e t

SUMMARY

In sutmary, the concept for this approach in accident prevention is to not simply detect and remove hazards. We must endeavor to identify and remove the higher-level management failures which pormitted the hazards to exist, and probably caused numerous other productive losses.

This system departs from the common principle that "the immediate supervisor is the key man in accident prevention." We contend that the immediate supervisor can do no more than is possible with the resources and authority that has been given to him.

Through this approach, the key and the basic responsibility for accident prevention are passed up to higher levels of management where there are power, influence and capability to direct that operations be conducted safely.

The buck is not passed down to the overburdened immediate supervisor who is of ten frustrated in his efforts to get approvals for his recommendations.

This system can easily be implemented by any safety personnel simply by starting to investigate all first aid injuries and hazardous situations with a manager's viewpoint.

Investigators must look at the Big Picture in every situation, and concentrate on finding the underlying management errors or over-sights that are responsible for many other hazards as well as other types of losses.

It is done simply by asking the question, "Where did Management Fail?"

whenever an accident occurs or a serious hazardous situation is noticed.

Experience shows that management errors can be found in practically all hazardous situations that are discovered, and substantial monetary savings in manpower and/or materials can be achieved in at least half of these cases by correcting the management errors.

The next step is to consolidate and summarize the minor problems to find major areas needing attentisn.

Savings as demonstrated in this report can be produced at any organization by the use of this concept and approach, savings that would not otherwise be realized.

Further, the approach will induce and promote better working relationships and understandings between safety personnel and line management.

9 22 I

i i